OMAHA, Neb. (AP)  Attorneys for a former doctor convicted of killing four people connected to an Omaha medical school began the effort Wednesday to spare him from the death penalty  even as he refused to help in his own defense.

Anthony Garcia appeared disheveled, with a heavy beard and unkempt hair, when he was wheeled into a Douglas County courtroom in a wheelchair. He appeared to sleep throughout the hearing and refused to engage in conversation with his attorneys, who presented hundreds of documents and interviews collected over years intended to show that he was mentally ill at the time of the killings.

Garcia”s lawyers hoped to present any mitigating factors  such as impaired mental capacity  that might save him from execution. Much of the evidence Garcia”s lawyers presented Wednesday sought to show Garcia as an alcoholic who suffered depression since childhood and mental illness that caused him to have invasive thoughts of hurting people.

Garcia, 45, of Terre Haute, Indiana, was convicted of fatally stabbing 11-year-old Thomas Hunter, son of Creighton University School of Medicine faculty member Dr. William Hunter, and the family”s housekeeper, 57-year-old Shirlee Sherman, in 2008 at the family”s home in an upscale Omaha neighborhood.

Garcia also was found guilty of two other killings in a separate incident five years later, the 2013 Mother”s Day deaths of another Creighton pathology doctor, Roger Brumback, and his wife, Mary, in their Omaha home.

His lead attorney, Jeff Pickens with the Nebraska Commission on Public Advocacy, on Wednesday painted the medical residency programs to which Garcia was accepted  including the Creighton program where Garcia worked for about a year  as “poor programs” that accepted Garcia simply to fill open positions.

“There”s a cruelty built into this case in that Mr. Garcia was set up to fail,” Pickens said.

Garcia”s parents attended the hearing, but Pickens said he did not plan to have them testify on Garcia”s behalf.

The jurors who convicted Garcia found evidence of several aggravating circumstances that could lead to his execution. A three-judge panel in Omaha will determine whether he will be sentenced to death or to life in prison. The sentence is not expected be announced for at least a month.

Nebraska has not executed an inmate since 1997, when the state”s method of execution was the electric chair. The state has since adopted a lethal injection protocol that has been fraught with controversy, legal challenges and difficulty in obtaining some of the drugs used to carry out lethal injection.